Society: AGA

Introduction:
A family history of gastric cancer (GC) is a risk factor for developing this malignancy and portends an increased risk of precursor lesions such as gastric intestinal metaplasia (GIM). Recent American Gastroenterological Association guidelines cite having a family history of GC as an indication for surveillance of GIM; however, evidence on the threshold to initiate screening and surveillance in these individuals and the intervals at which it should continue is lacking. The aim of this study was to assess the effectiveness and cost-effectiveness of screening and surveillance strategies in individuals with a family history of GC.

Methods:
A computer-based Markov simulation model of the natural history of progression from normal gastric mucosa to gastric cancer in a population of Americans with a family history of gastric cancer was developed and calibrated in TreeAge (TreeAge Pro 2020, Williamstown, MA). The model start age was 18 and it had a time horizon until age 100 or death. Cycle length was one month. Model inputs were derived from published literature. The model was used to compare five screening and surveillance strategies: one-time upper endoscopy bundled with colonoscopy at age 45, with surveillance every 3 years or every 5 years if GIM is diagnosed; surveillance at 3- or 5-year intervals irrespective of pathology; and no screening/surveillance. The primary outcomes were total cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). Secondary outcomes were cancer mortality and unadjusted life-years gained. A willingness to pay threshold of $100,000 per QALY was used to determine whether a strategy was cost-effective.

Results:
The cost-effective strategy was one-time upper endoscopy at age 45 with surveillance every 5 years if GIM is diagnosed. This corresponded to an ICER of $13,780/QALY, with an incremental gain of 0.23 QALYs compared to no screening/surveillance. The lifetime cancer mortality rate with this strategy was 1.93%, compared to 3.84% with no screening/surveillance. All other intervention strategies were dominated because they had higher costs and lower QALYs gained compared to the cost-effective strategy. Although cancer mortality was lowest with surveillance at 3-year intervals irrespective of pathology (0.29%), this was offset by lower incremental QALYs gained (0.031) compared to no screening/surveillance, and higher costs ($15,078).

Conclusions:
Based on our Markov model, one-time screening with surveillance every 5 years if GIM is diagnosed was effective and cost-effective in individuals with a family history of gastric cancer in the US context. While this can inform considerations regarding screening and surveillance recommendations, clinical studies will be vital to validating the potential benefits of preventative interventions in this high-risk population.

Table 1. Base-case analysis of a Markov model comparing screening and surveillance strategies in individuals with a family history of gastric cancer.

Table 1. Base-case analysis of a Markov model comparing screening and surveillance strategies in individuals with a family history of gastric cancer.

Introduction:
A high esophagogastroduodenoscopy (EGD) volume (~500 procedures per year) hospital in the southeastern United States had their automated endoscope reprocessor (AER) stop operating the day before twelve patients were scheduled for their procedures. Due to this situation, the facility would not be able to clean their reusable gastroscopes after procedure, thus rendering them unusable. To alleviate the potential backlog in patients, the facility utilized the Ambu aScope Gastro single-use gastroscope to perform all procedures as scheduled. To understand the impact of utilizing single-use more frequently in the facility, a cost analysis was performed to evaluate the impact of switching to single-use gastroscopes.
Methods:
Endoscope-related data from the facility was gathered including, but not limited to the following: procedure volume, quantity and price of gastroscopes and reprocessing equipment, scope reprocessing method, and repair costs. These variables were used to calculate a cost per use for the facility. An estimated number of additional procedures single-use gastroscopes may allow due to time and workflow efficiencies and average reimbursement amount were provided by the facility. Additional reimbursement and costs were calculated given the additional projected EGD procedures, and a final cost impact was calculated for a transition to single-use gastroscopes.
Results:
The cost analysis found that single-use gastroscopes would provide the facility a cost savings of $126.23 per procedure, or $37,867 a year. Per procedure, the facility would incur an additional equipment cost of $137.93, a reprocessing savings of $147.12, and a repair savings of $117.04 (Table 1). Due to increased workflow efficiencies, the facility projected an increase in the total amount of EGDs performed. This analysis assumed that single-use gastroscope could allow for 1 additional EGD a week, or 52 a year. With an average reimbursement of $15,500, the facility could see an additional $806,000 in yearly reimbursement for an additional cost of $14,469 (Table 2).
Conclusion:
Switching to single-use gastroscopes may not only provide facilities the ability to meet current demands in a time of need, but also promote cost savings as well as staff satisfaction and retention. Additionally, by allowing facilities to increase their procedure volume by improving workflow efficiency, single-use may also provide potential revenue generation. As the landscape of EGDs evolves, it will become even more important for facilities to evaluate their true cost per use and how single-use gastroscopes may impact it.

Background
Dyspepsia impacts over 20% of the global population and costs over $30 billion in healthcare-related and societal costs. American College of Gastroenterology (ACG) guidelines recommending a more judicious application of esophagogastroduodenoscopy (EGD) in the evaluation of dyspepsia in low-risk patients were published in 2017, but a prior single-center study showed adherence to this guidance is limited (Gupta et al. 2021). This study aimed to measure the uptake of ACG dyspepsia guidelines and factors associated with guideline adherence.

Methods
Patients aged 18-59 years who underwent outpatient EGD for dyspepsia or epigastric pain at 2 hospital-based endoscopy centers between 1/2018-12/2019 were included. Patients with a prior EGD, upper gastrointestinal surgery, or who had alarm symptoms were excluded. The co-primary outcomes were (1) the proportion of inappropriate EGDs, defined as those without H. pylori testing or a proton pump inhibitor [PPI] trial prior to EGD and (2) the proportion of potentially avoidable EGDs, defined as endoscopic and histologic findings of gastritis or H. pylori infection. Demographic and procedural factors associated with inappropriate or potentially avoidable endoscopies were explored in univariate analysis using chi square and in multivariable logistic regression.

Results
521 EGDs met our inclusion and exclusion criteria. The mean age of the patients undergoing EGDs was 43.2 years (SD: 11.1). Majority of patients were female (68.5%) and had commercial insurance (56%). 42% were Hispanic and 25% of EGDs had a fellow involved. 8.4% had an H. pylori test and 29.2% had a documented PPI prescription in the 2 years prior to EGD. 66% of EGDs were inappropriate and 39% were potentially avoidable by ACG guidelines. In univariable analysis, White race, non-Hispanic ethnicity, commercial insurance, tertiary care facility location, and lack of fellow involvement were each associated with inappropriate EGDs. Tertiary care facility location (OR 0.88, CI 0.57-1.34) and lack of fellow involvement (OR 0.46, CI 0.29-0.73) were independently associated with inappropriate EGDs when controlling for race, ethnicity, and insurance status in the multivariable analysis.

Discussion
In our cohort, adherence to ACG guidelines was low and a significant proportion of endoscopies were potentially avoidable. Fellow involvement was associated with guideline adherence despite prior work suggesting a limited impact of trainees on guideline adherence (Perez et al. 2012). Difficulty in completing H. pylori testing and treatment, varying levels of physician acceptance, as well as patient and provider beliefs regarding endoscopic evaluation are likely additional factors impacting guideline adherence but could not be measured in this study. Further analysis of the trainee effect is needed to improve adherence to the dyspepsia guidelines.

Ali Soroush

Icahn School of Medicine at Mount Sinai Department of Medicine

Appearances